Get (pca) Waiver Request Form - Ct

Filling out the Personal Care Assistance (PCA) Waiver Request Form is an essential step for individuals seeking support in Connecticut. This guide provides comprehensive instructions to help you successfully complete the form online.

Follow the steps to complete your (PCA) Waiver Request Form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your personal data. Fill in your full name, address, and date of birth. If someone else is the contact person, include their name and relationship to you, along with their telephone number.
3. Next, provide information related to your disability. Select your marital status and indicate whether you live alone or with others, and if applicable, provide a conservator's contact information.
4. Move on to the Medicaid/Medicare information section. Choose your current status regarding Medicaid and Medicare, and provide the respective numbers if applicable.
5. If you currently receive any services, check the relevant boxes and specify the number of hours per week for each service received. Additionally, identify the agency providing these services.
6. For other program participation, list any additional services you receive along with the total monthly cost if known. Include your social worker's details as necessary.
7. In the assistance needs section, check all areas where you require physical assistance, such as bathing or dressing.
8. Provide your financial data. Enter your total monthly income and assets, excluding amounts from the programs listed earlier. Specify the source of these funds.
9. If this form was completed by someone other than yourself, provide their information and relationship to you, along with an explanation.
10. Finally, attest to the accuracy of the information by signing the form. If applicable, ensure that any witnesses or conservators also sign and date the form.
11. After completing the form, you can save your changes, download, print, or share the form as needed.

Complete your PCA Waiver Request Form online today to ensure you receive the assistance you need.